Newly Insured by Health Law, Millions Face a Learning Curve

PHILADELPHIA - Advocates of the Affordable Care Act, focused until now on persuading people to buy health insurance, have moved to a crucial new phase: making sure the eight million Americans who did so understand their often complicated policies and use them properly.

The political stakes are high, as support for the health care law will hinge at least partly on whether people have good experiences with their new coverage. Advocates of the law also say teaching the newly insured how to be smart health care consumers could advance the law's central goal of keeping costs down, such as by discouraging emergency room visits, while still improving care.

For those reasons, hospitals, clinics, insurers and health advocacy groups around the country are organizing education efforts, aimed particularly at lower-income people who might not have had insurance in years, if ever. The Centers for Medicare and Medicaid Services has jumped in, too, with a project called 'From Coverage to Care,' which provides educational materials to community groups and medical providers who are trying to teach health and insurance literacy.

'It's not like you enroll and, voilà, you immediately know how to use it,' said Rebecca Cashman, a program coordinator for Resources for Human Development, a nonprofit group that is trying to help Philadelphians understand their new coverage. 'There are a lot of people who really have some big questions about 'what now?' '

Last week, Salwa Shabazz arrived at the office of a public health network here with a bag full of paperwork about her new health insurance - and an unhappy look on her face. She had chosen her plan by phone in March, speaking to a customer service representative at the federal insurance marketplace. Now she had problems and questions, so many questions.

'I've had one doctor appointment since I got this insurance, and I had to pay $60,' Ms. Shabazz told Daniel Flynn, a counselor with the health network, the Health Federation of Philadelphia. 'I don't have $60.'

Mr. Flynn spent almost two hours going over her Independence Blue Cross plan, which he explained had a 'very complicated' network that grouped doctors and hospitals into three tiers. Ms. Shabazz, who has epilepsy, had not understood when she chose the plan that her doctors were in the most expensive tier.

'None of that was explained when I signed up,' she said. 'This is the first I'm hearing it.'

Many people who signed up for private coverage through the new marketplaces had never had health insurance, and even the basics - like what a premium is and why getting a primary care doctor is better than relying on the emergency room - are beyond their experience. Others have a sense of how insurance works but find the details of the marketplace plans confusing, especially if they signed up without the help of someone who understood them.

In one sign of widespread confusion, a recent Kaiser Family Foundation survey of programs that helped people apply for marketplace coverage found that 90 percent had already been re-contacted by consumers with post-enrollment questions.

In the basement of a public library here last week, two of Ms. Cashman's colleagues gave a 'Health Insurance and You' presentation to about 15 people, some of whom took careful notes. Their group has made appearances all over the region in recent months, explaining things like the difference between an H.M.O. and a P.P.O., the importance of having a primary care doctor, and the choice between urgent care clinics and retail clinics like those in drugstores.

The two women who spoke at the library also offered tips, like looking at reviews on Angie's List to help choose a physician and taking a list of questions to the first meeting with a doctor.

'If they're not willing to answer your questions or take the time,' said Marieke Beck-Coon, one of the presenters, 'maybe you want to find someone else.'

Anita Crawford-Walton, 62, said she had come because looking for information on the website of her new insurer was overwhelming. Now she understands what a deductible is, she said, although she could not remember the size of the one for her plan. 'I've been going to my appointments, and so far everything that's come through has said, 'This is not a bill,' ' she said. 'That's good, right?'

Insurers, too, are trying to help ease their new members' confusion. Independence Blue Cross, which enrolled 165,000 people in its marketplace plans, has representatives traveling the Philadelphia region this summer in a tractor-trailer, the Independence Express, and offering educational seminars. Independence also has tried to reach all of the new members by phone to welcome them and 'make sure they understand what they bought,' said Paula Sunshine, the company's vice president of consumer sales and marketing.

Independence, the region's largest insurer, is also holding information sessions for health care providers and groups like Resources for Human Development and the Health Federation of Philadelphia, which help people enroll in marketplace plans and answer questions about them. It has also stocked its website, www.ibx.com, with short videos that explain things like prescription drug benefits and how to find a doctor.

'It's important that every place they turn they have access to answers,' Ms. Sunshine said of the new enrollees, half of whom Independence estimates were previously uninsured.

The company knew going in that the learning curve would be steep. It held focus groups last year with nearly 2,000 people and found, for example, that virtually none knew what coinsurance was. (It is the percentage a patient pays for some covered services.) The insurer is putting together a second round of focus groups to see if 'we closed the gap any compared to last year,' Ms. Sunshine said.

Independence has focused on making sure people understand the tiered-network plan that Ms. Shabazz chose, which was popular because of its relatively low price but also particularly hard to understand. Ms. Shabazz, 38, paid only about $32 a month in premiums, with federal subsidies of $218 covering the rest. But she could not afford the $60 co-payments to see her specialists on her annual income of $19,000.

Her financial situation worsened when she had to quit her job at the Pennsylvania Liquor Control Board in June because of the epilepsy, she said. She had called the federal marketplace to report her change in income, and had received a letter that she handed to Mr. Flynn, hoping he could explain it. The news, he said, was not good: With no more paychecks, she had fallen into the so-called coverage gap, earning too little to keep qualifying for the subsidies that made her premiums affordable, but likely still not qualifying for Medicaid because Pennsylvania has not expanded that program, as 26 states have under the Affordable Care Act.

'You'll probably have to cancel your plan,' he said. 'I wish I had a better solution for you.'

Ms. Shabazz's mother, Waheedah Shabazz-El, who had accompanied her to the appointment, shook her head as her daughter wiped away tears. 'There are so many layers to this,' Ms. Shabazz-El said.

Ms. Shabazz said she was relieved to finally figure out her plan, even though she would not be keeping it. 'I have a much clearer understanding now,' she said. 'But I'm still kind of sad. I'm worried.'